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Dr. Howard Michaels - Insurance CertificateG& 0 INS SERVICES PR99RAAMIYAE' 820 PARK ROW 5618 COMMERCIAL SAUNAS, CA 93901 Policy number. 04320437 -7 Underwritten by: United Financial Casualty Company Insured: HOWARD E MICHAELS CITY OF GILROY July 13, 2016 7351 ROSANNA ST GILROY, CA 95020 'PolicyPenod: Sep i, 2016 -Sep 1, 2017 Mailing Address United Financial Casualty Company PO Box 94739 Additional insured endorsement Cleveland, OH 44101 1- 800444.4487 For customer service, 24 hours a day, Name of Person or Organization 7 days a week CITY OF GILROY 7351 ROSANNA ST GILROY, CA 95020 The person or organization named above is an insured with respect to such liability coverage as is afforded by the policy, but this insurance applies to said insured only As aperson liable for the conduct of another insured and then only to the extent of that liability. We also agree with you that insurance provided by this endorsement will be primary for any power unit specifically described on the Declarations Page. Limit of Liability Bodily Injury Not applicable Property Damage Not applicable Combined Liability $ 1,000,000 each accident All other terms, limits and provisions of this policy remain unchanged. This endorsement applies to Policy Number: 04320437 -7 Issued to (Name of Insured): HOWARD E;MICHAELS Effective date of endorsement: 09/01/2016 Policy expiration date: 09/01/2017 Form 1198(01/04) G & 0 INS SERVICES 820 PARK ROW *618 SALINAS, CA 93901 CITY OF GILROY 7351 ROSANNA ST GILROY, CA 95020 Additional insured endorsement Name of Person or Organization CITY OF GILROY 7351 ROSANNA ST GILROY, CA 95020 PR99RF111YF COMMERC /AL Policy number: 04320437 -7 Underwritten by: United Financial Casualty Company Insured: HOWARD E MICHAELS July 13, 2016 Policy Period: Sep 1, 2016 - Sep 1, 2017 Mailing Address United Financial Casualty Company PO Box 94739 Cleveland, OH 44101 1 -800- 444 -4487 For customer service, 24 hours a day, 7 days a week The person or organization named above is an insured with respect to such liability coverage as is afforded by the policy, but this insurance applies to said insured only as a person liable for the conduct of another insured and then only to the extent of that liability. We also agree with you that insurance provided by this endorsement will be primary for any power unit specifically described on the Declarations Page. Limit of Liability Bodily Injury Not applicable Property Damage Not applicable Combined Liability $1,000,000 each accident All other terms, limits and provisions of this policy remain unchanged. This endorsement applies to Policy Number: 04320437 -7 Issued to (Name of Insured): HOWARD E MICHAELS Effective date of endorsement: 09/01/2016 Policy expiration date: 09/01/2017 Form 1198 (01104) Additional Insured Endorsement Name of Person or Organization CITY OF GILROY, ITS OFFICERS, OFFICIALS AND EMPLOYEES 7351 ROSANNA STREET GILROY, CA 95020 The person or organization named above Is an insured with respect to such liability coverage as Is afforded by the policy but this Insurance applies to said Insured only as a person liable for the conduct of another Insured and then only to the extent of that liability. We also agree with you that insurance provided by this endorsement will be primary for any power unit specifically described on the Declarations Page. Limit of Liability Bodily Injury each person/ Property Damage each accident Combined Liability $1,000,000 each accident All other terms, limits and provisions of this policy remain unchanged. This endorsement applies to Policy Number: 04320437 -6 Issued to (Name of Insured): HOWARD E MICHAELS each accident Effective date of endorsement: 09/01/2015 Policy expiration date: 09/01/2016 Form 1198 (01/04) Named Insured: Howard E. Michaels, MD Today's Date: August 4, 2015 Client ID: MICH011 Proposal Page 1 PROFESSIONAL LIABILITY INSURANCE RENEWAL PROPOSAL Insurance Carrier: Underwriters at Lloyd's, London A.M. Best rating: A.M. Best rating A XV Carrier status: Non - Admitted Policy period: 8/9/2015 - 8/912016 Professional Services: Medical Director Retro Date: 8/9/2005 Limits of Liability per claim/ annual aggregate: $1,000,000 Each Claim $3,000,000 Aggregate Deductible (per claim : $1,000.00 Each Claim Policy Premium: $4,985.00 25% Minimum Earned Premium applies Company Fee: $100.00 — Fully Retained at Inception Surplus Lines State Tax: $152.55 State Stamping Fee: $ 10.17 Total policy premium: $ 5,247.72 Affinity Commission: 11% Quote Expiration: 8/8/2015 This proposal must be signed, dated and returned to us prior to the quote expiration date as listed above. Our office cannot bind coverage until payment is processed by our office. Please sign /date and return via fax to 847 - 953 -4623, then mail originals with payment via mail. By signing this document I authorize Affinity Insurance Services, Inc. to bind coverage as outlined above. Signature: Date: X c Howard E. Michaels, MD I am paying via ❑ Check , -0 Finance Agreement ❑ Credit Card PLEASE CHECK APPLICABLE BOXES ABOVE. IF YOU ARE PAYING BY CREDIT CARD, WE WILL CONTA F 5'OU FROM A SECURE PHONE LINE IN ORDER TO PROTECT YOUR C EDIT CARD INFORMATION- PLEA OTE THE NAME OF THE PERSON TO CONTACT FOR CREDIT CARD PPj�MENT AND THE PHONE NUMBE O CALL: Contact Name Aonl Aon Affinity Physiaan Service Team 159 E County Line Rd I Hatboro, PA 19040 t + 1,866 -815 -5776 1 f + 1.800- 364 -1481 Contact phone number Named Insured: Howard E. Michaels ,MD Today's Date: August 3, 2015 Client ID: MICH011 Proposal Page 3 Company: Underwriters at Lloyd's, London Policy Term: 8/9/2015 - 81912016 Coverage Form: Medical Professional Liability - Claims Made and Reported PURCHASED COVERAGE ENHANCEMENTS (included in the premium): Sexual Misconduct: $100,000 / $300,000 xs $1,000 (Retroactive: August 9, 2014) Policy Endorsement Forms: APPLICABLE FORMS: (LMA3102) SLC- 3(COR) California (HAH- Dec003) Declarations Page (HAH- SchdForms) Schedule of Forms (HAH- Policy001GLCM) Allied Health Professional and General Liability Insurance (rev 7/13) Endorsement #1 : (NMA1331) Cancellation Clause Endorsement Endorsement #2 : (LSW1001) Several Liability Clause Endorsement #3 : (HAH- Endt016) Drop Down Limits Endorsement Endorsement #4 : (HAH- Endt023) General Liability Insurance Exclusion Endorsement Endorsement #5 : (HAH- Endt025) HIPAA Exclusion Endorsement Endorsement #6 : (HAH- Endt06O) Lloyd's Binding Authority Security Endorsement #7 : (HAH- Endt034) Medical Director Administrative Duties Extension Endorsement (Individual Version) -The City of San Jose The South Santa Clara County Fire District The City of Mountain View The City of Milpitas The City of Morgan Hill The City of Gilroy The City of Santa Clara Endorsement #8 : (HAH- Endt037) Minimum Earned Premium Endorsement Endorsement #9 : (HAH- Endt038) Named Insured Endorsement - Howard E. Michaels, M.D. APC DBA Second Opinion (Retroactive: August 9, 2013) Endorsement #10 : (HAH- Endt039) Physician, Dentist or Surgeon Exclusion Endorsement (Supplementary Exclusion) Endorsement #11 : (HAH- Endt05O) Sexual Misconduct Endorsement ERP Options: 12 months at 100 %, 24 months at 175% and 36 months at 225 %. Comments: CA DISCLOSURE: Please read, sign and return the enclosed D1 Aonl Aon Affinity Physician Service Team 159 E County Line Rd I Hatboro, PA 19040 t +1.866 -815 -5776 1 f +1 800 - 364.1481 Named Insured: Howard E. Michaels MD Today's Date: August 4, 2015 Client ID: MICH011 Compensation and Other Disclosure Information Affinity Insurance Services Inc. is an insurance producer licensed in your state. Insurance producers are authorized by their license to confer with insurance purchasers about the benefits, terms and conditions of insurance contracts; to offer advice concerning the substantive benefits of particular insurance contracts; to sell insurance; and to obtain insurance for purchasers. The role of the producer in any particular transaction involves one or more of these activities. Compensation will be paid to the producer, based on the insurance contract the producer sells. Depending on the insurer(s) and insurance contract(s) the purchaser selects, compensation will be paid by the insurer(s) selling the insurance contract or by another third party. Such compensation may vary depending on a number of factors, including the insurance contract(s) and the insurer(s) the purchaser selects. In addition, Affinity may charge a fee for administrative services. Your signature on your application, quote form, check, and /or other authorization for payment of your premium, will be deemed to signify your consent to and acceptance of the terms and conditions including the compensation, as disclosed above, that is to be received by Aon. The insurance purchaser may obtain information about compensation expected to be received by the producer based in whole or in part on the sale of insurance to the purchaser, and compensation expected to be received based in whole or in part on any alternative quotes presented to the purchaser by the producer, by contacting member services at 1- 800 -247 -1500. in addition, premiums paid by Clients to Affinity for remittance to insurers, Client refunds and claim payments paid to Affinity by insurance companies for remittance to Clients are deposited into fiduciary accounts in accordance with applicable insurance laws until they are due to be paid to the insurance company or Client. Subject to such laws and the applicable insurance company's consent, where required, Affinity will retain the interest or investment income earned while such funds are on deposit in such accounts. In placing, renewing, consulting on or servicing your insurance coverages Affinity and its affiliates may participate in contingent commission arrangements with insurance companies that provide for additional contingent compensation, if, for example, certain underwriting, profitability, volume or retention goals are achieved. Such goals are typically based on the total amount of certain insurance coverages placed by Aon with the insurance company or the overall performance of the policies placed with that insurance company, not on an individual policy basis. As a result, Aon may be considered to have an incentive to place your insurance coverages with a particular insurance company. Our liability to you, in total, for the duration of our business relationship for any and all damages, costs, and expenses (including but not limited to attorneys' fees), whether based on contract, tort (including negligence), or otherwise, in connection with or related to our services (including a failure to provide a service) that we provide in total shall be limited to the lesser of S6,000,000 or the singular annual limit of the policy of insurance procured by us on your behalf from which your damages arise. This liability limitation applies to you, our client, and extends to our client's parent(s), affiliates, subsidiaries, and their respective directors, officers, employees and agents (each a'-Client Group Member" of the "Client Group ") wherever located that seek to assert claims against ARS, and its parent(s), affiliates, subsidiaries and their respective directors, officers, employees and agents (each an "Aon Group Member" of the "Aon Group "). Nothing in this liability limitation section implies that any Aon Group Member owes or accepts any duty or responsibility to any Client Group Member. If you or any of your Group Members asserts any claims or makes any demands against us or any Aon Group Member for a total amount in excess of this liability limitation, then you agree to indemnify ARS for any and all liabilities, costs, damages and expenses, including attorneys' fees, incurred by ARS or any Aon Group Member that exceeds this liability limitation. Aon Corporation, our ultimate parent company, and its affiliates have from time to time sponsored and invested in insurance and reinsurance companies. While we generally undertake such activities with a view to creating an orderly flow of capacity for our clients, we also seek an appropriate return on our investment. These investments, for which Aon is generally at -risk for potential price loss, typically are small and range from fixed- income to common stock transactions. In such case, the gains or losses we make through our investments could potentially be linked, in part, to the results of treaties or policies transacted with you. Please visit the Aon website at lit �t:ihtivxv.aon.contvlmarket relationships for a current listing of insurance and reinsurance carriers in which Aon Corporate and its affiliates hold any ownership interest. Aon] Aon Affinity Physician Service Team 159 E County Line Rd I Hatboro, PA 19040 t +1.866 -815 -57761 f +1.800 - 364 -1481 MICHA:2 OP ID: RB 'AC C>RLX CERTIFICATE OF LIABILITY INSURANCE HATE acmmciYVrr) osr2snols THIS .CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE CO_ VERAGE AFFORDED SY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), .AUTHORIZED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER. _E _ _ _ IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policypes) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsemenL A statement on this. certificate does not confer rights to the certificate holder In 0eu of such endorsement(s). PRODUCER InsPro Agents & Brokers Ins. Ueense #OB18019 CONTAC NAME T Rhonda Buck x104 PHON E 408 -241 -0014 No 408-241-0037 4020 Moorpark X Avenue, #104 San .lose. CA L ADDRESS: IN AFFORDING COVERAGE NAIC s Inspro Agents&Brokers Ins Sery INSURER A: Sentinel ins Co.Ltd 07102/2016: EACH OCCURRENCE INSURED Howard Michaels, M.D. 5875 Killarney Cir San Jose, CA 95138 INSURER a GI ES (Ea o=mancs) wsuRER e : WSURER O S 10000_ INSURER E : INSURER F: COVERAGES CERTIFICATE NLIMRFR• - CMQINU.Ut IaAeGO. THIS 'IS SO CERTIFY THAT THE POLICIES OF' INSURANCE- LISTED'BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION "OVANY CONTRACT OR 'OTHER DOCUMENT WITH RESPECT TO WIi1CH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES: LIMITS SHOWN MAY HAVE BEEN REDUCED 'BY PAID CLAIMS. INSR TR TYPE OF INSURANCE ROM sum POLICY NUMBER POLICY EFF LIMITS A X COuMERCIALGENERALUABwfY_ .CLAIMS•MADE 0 OCCUR. 57SBANLS390 0710212015 07102/2016: EACH OCCURRENCE S 1,000,80 . _...__ GI ES (Ea o=mancs) S 300,00 MED EXP. are ewn S 10000_ X Hired NOA PERSONAL A ADV INJURY S 1;000,00 GENI AGGREGATE LIMIT APPLIES PER: POLICY ❑;EC LOC GENERAL AGGREGATE $ 2,000,00 .PRODUCTS - CONPIOPAGG- $ 2,000,00 Hired NOA s 1,000,0 OTHER: AUITOM0 MILE .LWBUITY BIN I IN U i 11000.00 A ANY auro 57SBANL5390 07/0212015 0710212016 80OLY INJURY (Par affam,) $ _ --' X --- _ _. -- - --- - - ALL OWNED SCHEDULED auros Auros HIRED AUTOS X NON -OWNED _ AUTOS -.. — —-- '- - - -' - -�'- BODILY INJURY (Par acddeM) $ 1.,000,00 DAMAGE sedda $ $ UMa E LA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS—MADE AGGREGATE $ DED RETENTION $ -$ WORKERS COMPENSATION - ' AND EMftoYW LIA811U1Y Y / N ANY PROPRIETORJPARTNEWEXECUTNE ❑ OFFICER469 MSER EXCLUDED? (dSandeforyWNH) If yes, dasvWe under DESCRIP ..TION.. OF OPERATIONS .below N /.A ER . E.L. .EACH ACCIDENT $ EL DISEASE- EA EMPLOYEE $ E.L. DISEASE - POLICY LIMB $ DESCRIPTION OF OPERATIONS / LOCATK)NS I VEMCLES (ACORD 101. Addlllwal Remwim 8ehedula, may be a8admd ff mac epees N requbed) City of Gilroy, IVs Officers Officials, and Employees are additional insured as required by;W ten contract Mth respect to operations of the named insured per form SS00080405 attached. CITY -15 City of Gilroy Gilroy Fire Department 7070 Chestnut Street Gilroy, CA 95020 SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORMED REPRESENTATIVE ®1988 -2014 ACORD CORPORATION. All rights reserved. ACOKO 25 (2014101) The ACORD name and logo'are registered marks of ACORD G & 0 INS SERVICES 820 PARK ROW #618 SALINAS, CA 93901 HOWARD E MICHAELS 5875 KILLARNEY CIRCL JAN JOSE, CA 95138 Additional insured endorsement Name of Person or Organization CITY OF GILROY 7351 ROSANNA ST GILROY,_CA 95020 Policy number. 04320437 -6 Underwritten by: .United Financial Casualty Company Insured: HOWARD E'MICHAELS July 15, 2015 Policy Period: Sep 1, 2015 - Sep 1, 2016 Mailing Address United Financial Casualty Company PO Box 94739 Cleveland, OH 44101 1. 800 - 444 -4487 For customer service, 24 hours a day, 7 days a week The person or organization named above is an insured with respect to such liability coverage as is afforded by the policy, but this insurance applies to said insured only as a person liable for the conduct of another insured and then only to the extent of that liability. We also agree with you that insurance provided by this endorsement will be primary for any power unit specifically described on the Declarations Page. Limit of Liability ___Bodily Injury _ __ _ Not applicable _ Property Damage Not applicable Combined Liability $1,000,000 each accident All other terms, limits and provisions of this policy remain unchanged. This endorsement applies to Policy Number: 04320437 -6 Issued to (Name of Insured): HOWARD E MICHAELS Effective date of endorsement: 09/01/2015 Policy expiration date: 09/01/2016 Form 1198 (01104) MICHA -2 OP ID: RB CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 0612612015 -THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy((es) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER InsPro Aggents & Brokers Ins. License 10e BI 4020 Moorpark Avenue, 9104 San Jose, CA 95117 Inspro AgentsBBrokers Ins Sery CONTACT Rhonda Buck x104 PHONE'- FAX (arc No. Ext :408 - 241 -0014 aC No): 4O8- 241 -0037 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Sentinel Ins Co Ltd 07/02/2018 _ INSURED Howard Michaels, M.D. INSURE RB: PREMISES (Ea occurrence) 5875 Killarney Cir San Jose, CA 95138 INSURER C: MED EXP (Any one person) 1 X Hired NOA URERD $ 1,600,000_ -INSURER INSURER E: GENERAL AGGREGATE $ 2,000,00 "INSURER F: $ 4666006 Hired NOA rnVFROGFS CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, -THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSIR LTR TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFE MM/DDNYYY POLICY EXP MM /DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE �1OCCUR 67SBANL5390 I I 0710212015 - 07/02/2018 EACH OCCURRENCE $ 1,000,00 PREMISES (Ea occurrence) $ 300,000 MED EXP (Any one person) $ 16,000 X Hired NOA PERSONAL 8 ADV INJURY $ 1,600,000_ GENT AGGREGATE LIMIT APPLIES PER POLICY a PRO- JECT ❑ LOC OTHER: - GENERAL AGGREGATE $ 2,000,00 PRODUCTS - COMP /OP AGG $ 4666006 Hired NOA $ 1,000,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X X NON -OWNED HIRED AUTOS AUTOS 57SBANL5390 07/0212015 0710212016 COMBINED SINGLE LIMIT Ea accident $ 1 �OQ6,66 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ 0 0 000,0 1,000,000 PeOPERT DAMAGE $ $ UMBRELLALIAB EXCESS LJAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ -_$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A I ST H STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) City of Gilroy, it's Officers: Officials, and Employees are additional insured as required by written contract with respect to operations of the named insured perform SS00080405 attached. City of Gilroy Gilroy Fire Department 7070 Chestnut Street Gilroy, CA 95020 ACORD 25 (2014/01) CITY -15 LW-110"M SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1 The ACORD name and logo are registered marks of ACORD riahts . POLICY NUMBER: 57 SBA NL5390 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON- ORGANIZATION CITY OF GILROY, ITS OFFICERS, OFFICIALS AND EMPLOYEES 7070 CHESTNUT STREET GILROY, CA 95020 Form 1H 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 001 Process Date: 04/15/15 Expiration Date: 07/02/15 BUSINESS LIABILTY COVERAGE FORM SS00080405 THE HARTFORD WHO IS AN INSURED Additional Insureds When Required By Written Contract, Written Agreement or Permit The person(s) or organization(s) identified in Paragraph f. below is additional insured when you have agreed, in a written contract, written agreement or because of a permit issued by a state or political subdivision, that such person or organization be added as an additional insured on your policy, provided the injury or damage occurs subsequent to the execution of the contract or agreement, or the issuance of the permit.. f. Any Other Party (1) Any person or organization but only with respect to liability for "bodily injury" "property damage" or "personal and advertising injury" caused , in whole or part, by your acts or omissions or the acts or omissions of those acting on your behalf: (a) In the performance of your ongoing operations; (b) In connection with your premises owned by or rented to you or, (c) In connection with "your work" and included within the "products completed operations hazard ", but only if (1) the written contract or written agreement requires you to provide such coverage to such additional insured; and (II) this Coverage Part provides coverage for "bodily injury" or "property damage" included within the "products completed operations hazard" (2) With respect to the insurance afforded to these additional insureds, this insurance does not apply to :. "Bodily injury" "property damage" or "personal or advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services including: (a) The preparing, approving or failure to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders; designs or drawings and specifications or (b) Supervisory inspection or architectural or engineering activities. The limits of insurance that apply to additional insureds is described in Section D. Limits of Insurance. How this insurance applies when other insurance is available to an additional insured is described in the Other Insurance Condition in Section E. Liability and Medical Expenses General Conditions. No Person or Organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a Named Insured in the Declarations. Primary Insurance When Required By Contract - This insurance is primary if you have agreed in a written contract, written agreement or permit that this insurance is primary. If other insurance is also primary, we will share with all that other insurance by the method described in c. Method of Sharing. Primary And Non - Contributory To Other Insurance When Required By Contract— If you have agreed in a written contract, written agreement or permit that this insurance is primary and noncontributory with the additional insured's own insurance, this insurance is primary and we will not seek contribution from that other insurance. Waiver Of Rights Of Recovery (Waiver of Subrogation) — If the insured has waived any rights of recovery against any ;person or organization for all or part of any payment, including Supplementary Payments, we have made under this Coverage Part, we also waive that right, provided the insured waived their rights of recovery against such person or organization in a contract, agreement or permit that was executed prior to the injury or damage. This is a portion of form SS00080405 (The Hartford 2005) for reference. only. This is not intended to afford coverage to any person or organization. The entire 24 page form is available for review upon request. MICHA -2 OP ID: RB CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 0610412014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURE-R(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER InsPro Agents & Brokers Ins. License #OB18019 4020 Moorpark Avenue, #104 San Jose, CA 95117 Inspro Agents &Brokers Ins Sery CONTACT CT Rhonda Buck PHON' FAK AIC o 841 1 Arc No: 408 -241 -0037 ADDRIL INSURER(S) AFFORDING COVERAGE NAIL 9 INSURERA: Sentinel Insurance Co Ltd INSURED Howard Michaels, M.D. 5875 Killarney Cir San Jose, CA 95138 INSURER B: EACH OCCURRENCE INSURER C : INSURER D: INSURER E: 57SBANL5390 07/02/2014 INSURER F PREMISES Ea occurrence COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR — TYPE OF INSURANCE INSO WVQ POLICY NUMBER MM/DD MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE OCCUR 57SBANL5390 07/02/2014 07!0212015 PREMISES Ea occurrence $ 3.00,000 MED EXP (Any one person) $, 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN -L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,0001000 POLICY PECT LOC PRODUCTS- COMP /OP AGG $ 2,000;000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person), $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ EXCESS LIAB OED J I RETENTION $ $ . WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE F7 OFRCERlMEMBER EXCLUDE D9 (Mandatory In NH) N! A STATUTE ER H E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -. POLICY LIMIT - . $ DESCRIPTION OF OPERATIONS I LOCATIONS? VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) City of Gilroy, it's Officers, Officials, and Employees are additional sured as required by written contract with respect to operations of the- named insured per form SS00080405 attached. CERTIFICATE HOLDER CANCELLATION CITY -15 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Gilroy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Gilroy Fire Department 7070 Chestnut Street Gilroy, CA 95020 AUTHORIZED REPRESENTATIVE ACORD 25- (-2014101) O 1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 90 This Spectrum Policy consists of the Declarations, Coverage Forms, Common Policy Conditions and any 53' other Forms and Endorsements issued to be a part of the Policy. This insurance is provided by the stock NI; insurance company of The Hartford Insurance Group shown below. SBA INSURER:. SENTINEL INSURANCE COMPANY, LIMITED ONE HARTFORD PLAZA, HARTFORD, CT 06155 COMPANY CODE: A THE Policy Number: 57 SBA NL5390 SC HARTFORD SPECTRUM POLICY DECLARATIONS ORIGINAL rn Named Insured and Mailing Address: HOWARD MICHAELS, M.D. o (No., Street, Town, State, Zip-Code). 5875 KILLARNEY CIRCLE in SAN JOSE CA 95138 Policy Period: From 07/02/14 To 07/02/15 1 YEAR 12:01 a.m., Standard time at your mailing address shown above. Exception: -12 noon in New Hampshire. Name of Agent /Broker: INSPRO AGENTS & BROKERS INS SRVCS Code: 152163 Previous Policy Number: 57 SBA NL5390 Named Insured is: CORPORATION Audit Period: NON - AUDITABLE Type of Property Coverage: SPECIAL Insurance Provided: In return for the payment of the premium and subject to all of the terms of this policy, we agree with you to provide insurance as stated in this policy. TOTAL ANNUAL PREMIUM IS: $500 MP Countersigned Re Form SS 00 02 12 06 Page 001 (CONTINUED ON NEXT PAGE); Process Date: 04/18/14 Policy Expiration Date: 07/'02/15 INSURED COPY Date SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 57 SBA NL5390 Location(s), Building(s), Business of Named Insured and Schedule of Coverages for Premises as designated by Number below. Location: 001 Building: 001 5875 KILLARNEY CIRCLE SAN JOSE CA 95138 Description of Business: Consultant - NOC Deductible $ 250 PER OCCURRENCE BUILDING AND BUSINESS PERSONAL PROPERTY LIMITS OF INSURANCE BUILDING BUSINESS PERSONAL PROPERTY REPLACEMENT COST PERSONAL - PROPERTY OF OTHERS REPLACEMENT COST MONEY AND SECURITIES INSIDE THE PREMISES OUTSIDE T.HE PREMISES Form SS 00 02 12 06 Process Date: 04/18/14 NO COVERAGE $ 4,800 NO COVERAGE $ 10,000 $ 5,000 Page 002 (CONTINUED ON NEXT PAGE) Policy Expiration Date: 07/02/15 m rn 0 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 57 SBA NL5390 Location(s), Building(s), Business of Named Insured and Schedule of Coverages for Premises as designated by Number °below. Location- 001 Building: 001 PROPERTY OPTIONAL COVERAGES APPLICABLE LIMITS OF INSURANCE TO THIS LOCATION STRETCH COVERAGES FORM: SS 04 08 THIS FORM INCLUDES MANY ADDITIONAL COVERAGES AND EXTENSIONS OF COVERAGES. A SUMMARY OF THE COVERAGE LIMITS IS ATTACHED. LIMITED FUNGI, BACTERIA OR VIRUS $ 50,000 COVERAGE: FORM SS 40 93 THIS IS THE MAXIMUM AMOUNT OF INSURANCE FOR THIS COVERAGE, SUBJECT TO ALL PROPERTY LIMITS FOUND ELSW ON THIS DECLARATION. INCLUDING BUSINESS INCOME AND EXTRA EXPENSE COVERAGE FOR: 30.DAYS Form SS 00 02 12 06 Process Date: 04/18/14 Page 003 (CONTINUED ON NEXT PAGE) Policy Expiration Date: 07/02/15 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 57 SBA NL5340 PROPERTY OPTIONAL COVERAGES APPLICABLE LIMITS OF INSURANCE TO ALL LOCATIONS BUSINESS INCOME AND EXTRA EXPENSE COVERAGE COVERAGE INCLUDES THE FOLLOWING COVERAGE EXTENSIONS: ACTION OF CIVIL AUTHORITY: n EXTENDED BUSINESS INCOME: EQUIPMENT BREAKDOWN COVERAGE COVERAGE FOR DIRECT PHYSICAL LOSS DUE TO: MECHANICAL BREAKDOWN, ARTIFICIALLY GENERATED CURRENT AND STEAM EXPLOSION THIS ADDITIONAL COVERAGE INCLUDES THE. FOLLOWING EXTENSIONS HAZARDOUS SUBSTANCES EXPEDITING EXPENSES MECHANICAL BREAKDOWN COVERAGE ONLY APPLIES WHEN BUILDING OR BUSINESS PERSONAL PROPERTY IS SELECTED ON THE POLICY IDENTITY RECOVERY COVERAGE FORM SS 41 12 Form SS 00 02 12 06 Process Date:04/18/14 12 MONTHS ACTUAL LOSS SUSTAINED 30 DAYS 30 CONSECUTIVE DAYS $ 50,000 $ 50,000 $ 15,000 Page 004 (CONTINUED ON NEXT PAGE) - _Policy Expiration Date: 07/02/15 m rn 0 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 57 SBA NL5390 BUSINESS LIABILITY LIABILITY AND MEDICAL EXPENSES MEDICAL EXPENSES -ANY ONE PERSON PERSONAL AND ADVERTISING INJURY DAMAGES TO PREMISES RENTED TO YOU ANY ONE PREMISES AGGREGATE LIMITS PRODUCTS - COMPLETED OPERATIONS FORM SS 05 09 GENERAL AGGREGATE BUSINESS LIABILITY OPTIONAL COVERAGES SIRED /NON -OWNED AUTO LIABILITY Form SS 00 02 12 06 . Process Date: 04/18/14 LIMITS OF INSURANCE $1,000,000 $ 10,000 $1,000,000 $1,000,000 $2,000,000 $2,000,000 $1,000,000 Page 005 (CONTINUED ON NEXT PAGE) Policy Expiration Date: 07/02/15 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 57 SBA NL5390 Form Numbers of Forms and Endorsements that apply: SS 00 01 03 14 SS 00 45 12 06 SS 04 19 04 0`9 SS O4 39 07 05 SS 04 45 07 05 SS 40 18 07 05 SS 41 62 06 11 SS 05 47 09 01 SS 04 46 10 08 SS 00 05 10 08 SS 84 01 09 07 SS 04 22 07 05 SS 04 41 04 09 SS 04 47 0409 SS 40 93 07 05 SS 41 63 06 11 SS 50 19 03 12 SS 38 25 12 01 SS 00 07 07 05 SS 01 21 07 08 SS 0.4 30 07 05 SS 04 42 09 07 SS 04 80 03 00 SS 41 12 12 07 IH 10 01 09 86 IH 99 40 04 09 SS 83 76 03 12 SS 00 08 04 05 SS 04 08 09 07 SS 04 38 09 09 SS 04 44 07 05 SS 04 86 03 00 85 41 51 10 09 SS 05 09 07 00 IH 99 41 04 09 c.. Form SS 00 02 12 06 Page 006 Process Date: 04/18/14 Policy Expiration Date: 0 7 / 02 / 15 G & 0 INS SERVICES 820 PARK Abw #618 SALINAS, CA 93901 646107 17709 1 AT 0.406 PPACSO1 C 069 017709 Named insured HOWARD E MICHAELS 5875 KILLARNEY CIRCL JAN JOsE, CA 95138 IIIIII�11�11111 1111" III11" LII�II�IIIIIIIIIIIIIIIIIIIIifI1I1111 Commercial Auto Insurance Coverage Summary This is your Declarations Page Your coverage has changed r��i Policy number: 04320437 -4 Underwritten by: United Financial Casualty Company August 15, 2014 Policy Period: Sep 1, 2013 - Sep 1, 2014 Page 1 of 3 progressiveagent.com Online Service Make payments, check billing activity, print . policy documents, or check the status of a claim. 1-831- 998 -7856 - - G & 0 INS SERVICES Contact your broker for personalized service. 1- 800 -444 -4487 For customer service if your broker is unavailable or to report a claim. Your coverage began on September 1, 2013 at 12:01 a.m. This policy expires on September.1, 2014 at 12:01 am, This coverage summary replaces your prior one. Your insurance policy and any policy endorsements contain a full explanation of your coverage. The policy limits shown for an auto may not be combined with the limits for the same coverage on another auto, unless the policy contract allows the stacking of limits. The policy contract is form 6912 (06/10). The contract is modified by-forms 2852CA (09/06), 4757 (03/05), 1198 (01104), 8610 (05/09), Z311 (11/07), 2313 (05/07), 4852CA (10/04), 4881CA (12/04) and Z228 (01/11) The named insured organization type is a sole proprietorship. Policy changes effective August 14, 2014 ................................................................................ ........ .......... ........................... .... ........... ............................... Premium change: $0.00 .................................._...................,....................,............ ............................... Changes: The mailing address information has changed. The changes shown above will not be effective prior to the time the changes were requested. Continued Form 6489 CA (06 /10) Policy number: 04320437 -5 HOWARD E MICHAELS Page 2 of 3 Outline of coverage Description Limits ............................... Deductible Premium •. ............................... .....:....................................................................................................... Liability To Others $884 Bodily Injury and Property Damage Liability $1,000,000 combined single limit UninsuredNnderinsured Motorist $1,000,000 combined single limit 168 Uninsured Motorist Property Damage Rejected Medical Payments $5,000 each person 33 Comprehensive 121 See Auto Coverage Schedule Limit of liability less deductible Collision 230 See Auto Coverage Schedule Limit of liability less deductible Re'n't' a*1 Reimbursement 43 See Auto Coverage Schedule ..................... .....:.............................................................................................................................. ............................... Roadside Assistance 20 See Auto Coverage Schedule Subtotal policy premium $1,499.00 .............................................................................................................................................. California Vehicle Assessment Fee ..................................... ............................... •....... •_................................................................ ............................... 1.75 Fees ................._............. 100.00 Total 12 month policy premium and fees ................ $1,600.75 Rated driver ............................................................................................... 1. HOWARD E MICHAELS ............................... Auto coverage schedule 1. 2004 Lexus GX 470 Actual Cash Value (plus $2,000.00 Permanently Attached Equip) V s VIN; JTJBT20X640033564 Garaging Zip Code: 95012 Radius: 200 0 0 0 Liability Liability uM/uIM BI Med Pay x o .................... Premium $884 $168 ........................_....... $33 ................_.............. .............. o a Comp Camp Physical Damage Deductible Premium Collision Deductible Collision Premium o ............................................................ Premium _ $500 $121 $500 ............................... $230 a Rental Rental Other Coverages Limit Premium Roadside Limit Roadside Premium Auto Total a °' ................_............................................................................................................ Premium $30 per day $43 Selected $20 ............._.........,. $1,499 Max $900 Premium discounts Policy .............. ............................... •....................... 04320437 -5 Business Experience and Paid In Full Additional Insured information .................................. C. IT..... O...... I G..R....................................... .. . ............................................ 1 , Additional Lnsured Y F LOY .. 7351 ROSANNA ST GILROY, CA 95020 ........................................................................................................................................... ............................... 2. Additional Insured S SANTA CLARA FIRE 15670 MONTEREY MONGAN HILL, CA 95037 Continued Form 6489 CA (06/10) Policy number: 04320437 -5 HOWARD E MICHAELS Page of 3 3. .................................................................................................................... Additional Insured ............................... CITY OF MILPITAS 455 E CALAVERAS MILPITAS, CA 95035 4. ...................................................................................................................... Additional Insured ............................... CITY OF SAN JOSE 1661 SENTER AVE SAN JOSE, CA 95112 5 . ...................................................................................................... Additional Insured ............................... CTY OF SNTA CLRAFD 777 BENTON ST SANTA CLARA, CA 95050 6. Additional Insured ............................. CITY OF MT VIEW FD 1000 VILLA ST MT VIEW, CA 94041 Company officers K"Ij- &VA President Form 6489 CA (06/10) Secretary Robert Varich . 1125 Saratoga Ave San Jose CA 95129 ✓ Verify the information listed In the Policy Declarations. ✓ Please calla you have any questions. ✓ Now you can pay your premium before your bill. is issued - visit allstate.com or call 1- 800 - Allstate ®. 1111111 JillI�I'�"lll�ll�l� Howard- &- Jane _Michaels 5875 Killarney Cir San Jose CA 95138 -2347 A new policy period is about to begin. Here are your renewal materials. We're pleased to once again offer you the opportunity to continue your policy for another year. Your Allstate Insurance Company Personal Umbrella policy is just one of an array of products we offer to meet a wide variety of insurance needs, and we appreciate your business. Your policy documents are inside. You'll find listed on the enclosed Policy Declarations your coverages, limits, deductibles, premiums, and any discounts you may have. As you read these materials, it would be a. good idea to consider whether anything needs updating. We'd be happy to help you make sure that your insurance stays current with any changes in your life. (over) PROP 600000914698196 088 610, CA IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIOIIIIIIIIIIIIkI �_ ��• Renewing your policy is easy. Here;s what will happen and what you'll need to do before the beginning of your next policy period. • Please carefully check your Policy Declarations to make sure it accurately reflects your information and the choices you've made. Get in touch with your agent right away if there's anything you'd like to change. • Keep an eye out for your bill, which will include information on payment options. • If you're paying your premium using the Allstate Easy Pay Plan, you will not receive a bill. Instead, we'll send you a statement detailing your withdrawal schedule for the policy period. • Carefully read all enclosed materials and store these documents with your other important papers. Keep in mind that the policy documents included may change each time you receive a renewal offer — please read them to make sure you know about any important information or changes related to your insurance. We're here to help you. Feel free to call your agent at (408) 257-1234. Or take advantage of the online services at allstate.com, where you can view account information or check claim status by registering at the Allstate Customer Care Center. Remember, insurance is not only protection for today. It helps pave the way to a financially secure future. We're glad you're with us. .4�� Alu- Thomas J. Wilson President, Allstate Insurance Company 1401095304310 41082280 Allstate Insurance Company RENEWAL Personal Umbrella Policy Declarations Summary NAMED INSURED(S) YOUR ALLSTATE AGENT IS: CONTACT YOUR AGENT AT: Howard & Jane Michaels Robert Varich (408) 257 -1234 5875 Killarney Cir .1125 Saratoga Ave Jose ose CA 95138 -2347 San Jose CA 95129 POLICY NUMBER POLICY PERIOD PREMIUM PERIOD 9 14 698196 02/24 Begins on Feb. 24, 2014 Feb. 24, 2014 to Feb. 24, 2015 Ends on Feb. 24, 2015 at 12:01 a.m. Pacific Time Total Premium for the Premium Period (Your bill will be mailed separately) Excess Liability $794.00 Dwelling(s) Rented to Others $23.00 TOTAL $817.00 See the Important Payment and Coverage information section for details about installment fees. ✓ Premium includes a charge for 9 automobiles PROP '510060414010953043100602' Allstate Insurance Company Policy Number: 914 698196 OZ24 Your Agent Robert Varich (408) 257.1234 For Premium Period Beginning: Feb. 24, 2014 REQUIRED UNDERLYING INSURANCE LIMITS COVERAGE REQUIRED UNDERLYING LIMIT Residence/Farm Premises $300,000 Residence/Farm Employees $300,000 (Bodily Injury or Property Damage Liability or Single Limit Liability) Additional Dwelling Rented to Others $300,000 (Bodily Injury or Property Damage Liability or Single Limit Liability) Incidental Office, Private School or Studio $300,000 Bodily Injury or Property Damage Liability or Single Limit Liability $100,000 each person (This coverage may maintained as part of your Comprehensive $300,000 each accident Personal Liability, Homeowners Liability Insurance or similar $100,000 package policy) Automobiles $300,000 Bodily Injury Liability $250,000 each person by one or more outboard motor with more than 25 total horsepower, $500,000 each accident Property Damage Liability $100,000 Or Single Limit Liability $500,000 For each Automobile you own, maintain or use Recreational Motor Vehicles Bodily Injury Liability $100,000 each person $300,000 each accident Property Damage Liability $100,000 Or Single Limit Liability $300,000 Watercraft Bodily Injury Liability $100,000 each person $300,000 each accident Property Damage Liability $100,000 Or Single Limit Liability $300,000 For each Watercraft 26 feet or more in length, or powered by one or more outboard motor with more than 25 total horsepower, or which has total motor power of more than 50 horsepower. For Boats not described above: Single Limit Liability $300,000 (This coverage may be maintained as part of your Comprehensive Personal Liability, Homeowners Liability Insurance or similar package policy) Imorme0on ae of Page 2 January 9,2D14 CAOBBR80 Allstate Insurance Company Policy Number: 9 14 698196 02)14 Your Agent. Robert Varich (406) 257 -1234 For Premium Period Beginning: Feb. 24, 2014 POLICY COVERAGES AND LIMITS OF LIABILITY COVERAGES LIMITS OF LIABILITY Excess Liability $5,000,000 each occurrence (EXCESS INSURANCE FOR LIABILITY TO THIRD PARTIES ONLY) Your Policy Documents Your Personal Umbrella policy consists of this Policy Declarations and the documents listed below. Please keep these together. -- Personal Umbrella Policy form AP128 - California PUP Amendatory End. form AP1310 - CA Pers Umbrella .Policy Amend End form AP2306-1 Important Payment and Coverage Information Please note: This is not a request for payment Your bill will be mailed separately. If you decide to pay your premium in installments, there will be a $3.50 installment fee charge for each payment due. If you make 6 installment payments during the policy period, and do not change your payment plan method, then the total amount of installment fees during the policy period will be $21.00. If you are on the Allstate ® Easy Pay Plan, there will be a $1.00 installment fee charge for each payment due. If you make 6 installment payments during the policy period, and remain on the Allstate ® Easy Pay Plan, then the total amount of installment fees during the policy period will be $6.00. If you change payment plan methods or make additional payments, your installment fee charge for each payment due and the total amount of installment fees during the policy period may change or even increase. Please note that the Allstate Easy Pay Plan allows you to have your insurance payments automatically deducted from your checking or savings account. WHEREOF, Allstate has caused this policy to be signed by two of its officers at Northbrook, if required by state law, this policy shall not be binding unless countersigned on the Policy by an authorized agent of Allstate. A,&- (I J. Wilson Mary J. McGinn President Secretary jPROP IIIIIIIIIIIIIIIIIIIIINIIII111111111111111111H111 -.. CAMRBD Allstate Insurance Company Policy Number: 9 14 696196 02)24 Your Agent Robert Varich (406) 257 -1234 For Premium Period Beginning: Feb. 24, 2014 POLICY PROVISIONS: Rates, Policy Forms and Payment of Premiums: Applicable only with respect to policies issued on a continuous basis. 1. The rates and policy forms in effect for the company upon the inception date of the insurance evidenced hereby, and upon each successive anniversary date, shall apply. 2. The phrase "Policy Period" as used in the policy shall be deemed to mean that period of time while the applicable coverage of the policy is in force. 3. The named insured shall pay the required premium in advance of each successive premium period, and upon notice of interim amendments. IMPORTANT NOTICE- - - CONCERNING THE INSURANCE YOU MUST MAINTAIN (Not a part of the Policy) Please read the following provisions of the policy carefully: (1) Required Underlying Insurance It establishes the types of insurance and the limits you must maintain. If, during the policy period, additional liability exposures exist, check the list of Required Underlying Insurance on the policy declarations and secure any needed underlying coverage and limits. In the event that you fail to maintain the Required Underlying Insurance you may be required to personally incur or expend substantial sums of money for your legal defense and for payment of damages, and with respect to which Allstate has no obligation to pay or provide reimbursement to you. (2) Retained Limits It identifies the amount of any damages an insured must pay for any occurrence. (3) In the event that additional exposures are acquired after the issuance of this policy, please notify Allstate of the additional exposure as soon as practicable. None of the terms and conditions of the policy are modified by this Important Notice. ino' iiiiiiiiiimiiimimimiiinmiimiiiiiii